“All-Payer” Claims Data versus State Data: Demystifying Healthcare Analytics

When it comes to market analysis, many healthcare data sources offer varying degrees of insight, completeness and latency. There are two primary sources used by healthcare organizations: all-payer claims data and state data. Many of our clients have asked for our opinion on which offers better insights. To weigh the best source for your needs, you’ll want to consider the nature of the data and the most appropriate use cases. Here’s an overview comparing claims data to state data, along with insights based on our experience.

Where Does the Data Come From?

First, let’s assess the typical source of each type of data.

  “All-Payer” Claims Data State Data
What is it? Adjudicated claims data (837s) passed electronically from providers to payers Encounter data from electronic health record systems
Where does it come from? Sourced typically via clearing house transactions; aggregated by claims consolidators Submitted by hospital or healthcare entities based on state requirements (varies state to state)
What does it include? Claims that any healthcare entity or provider has submitted to be reimbursed; highly focused on commercially-insured claims, representing transactions where consumers may have more choice 

All encounters that meet reporting requirements, including self-pay records

Typically focused on inpatient encounters; outpatient is often optional

How Does the Data Compare?

Now that we know where the data comes from and what it includes, let’s see how each compares for different uses.

  All-Payer Claims Data State Data
Measuring Volumes & Utilization

Volumes can be calculated based on a variety of discrete fields

Populi calculates claims volumes three ways: unique patients, claims and procedure/diagnosis code-level counts

Volumes are typically calculated at the encounter level
Inclusions / Exclusions Includes all types of healthcare organizations and providers, including independent physician practices Facilities are usually limited to hospitals and hospital systems (based on who is required to submit data to the state)
Types of Analysis

Claims share, market size, market utilization, volumes and referral analysis

Datasets are de-identified, but Populi uses patient tokens to create longitudinal datasets in a compliant manner (e.g., referral analytics), which expands available use cases

Inpatient market share, inpatient market size, hospital utilization and volumes analysis

Datasets are completely de-identified; use cases are primarily focused on inpatient utilization and market share

Which Data Is Better?

Both are helpful in different ways!

There are applications and needs for both claims and state data in healthcare market analysis. A robust market analytics program will leverage both types of data, which offer different perspectives, as shown in the examples below.

Business Question All-Payer Claims Data State Data
Market Share or Claims Share: How is your organization positioned in the market?

Provides a narrower view of commercially-insured, Medicare and other payer categories such as supplemental Medicare plan volumes, which represents a higher-focus population for most health systems

Includes all types of volumes across many different healthcare entities that may not be required to submit data to the state; offers much deeper insights into the global outpatient, various ambulatory and clinic settings of care

Provides a holistic view of inpatient market share across hospital entities, and depending on the state requirements, may also include some hospital-based outpatient market share

Includes all types of volumes regardless of payer, to help assess charity care, self-pay and state Medicaid volumes

Market Size & Utilization: What healthcare services are consumers using and how much? Same as above, but offers much more detail on upstream ambulatory/clinic utilization by patients, which can be predictors of downstream, specialty and procedural care Same as above, and can often be used for inpatient quality and capacity (bed) management
Referral or Network Integrity Analysis: Which providers are sharing patients and how often are patients staying in my network?

Robust, longitudinal studies are viable that draw connections between providers based on shared patients (implicit referral analysis)

Sometimes the referring provider is included on the claims (explicit referral analysis)

Includes the ability to create market views inclusive and exclusive of your healthcare organization and providers, allowing you to understand broader overall activity and new opportunities in your market

Often includes the attending physician to help you understand who is seeing patients, especially in the inpatient setting, but no referral insights

Benchmarking: How do my providers compare to other providers; how does my geography compare to other similar geographies?

National, regional, state  and local benchmarks are viable

Robust comparisons can be made across similar types of providers or facilities, service lines/sub service lines and procedure codes, as well as similar geographic regions or core-based statistical areas (CBSAs)


Comparisons within a state are available

Comparisons between states may be available if multiple states’ data are acquired; however, all states have different reporting requirements and produce different reports, so it may be difficult to blend the data for comprehensive analysis

The Solution is Both / And

Claims and state data are very distinct based on sourcing and the available detailed inclusions. However, they can both be helpful to produce holistic and complementary market analyses.

While state data tends to be used more widely for inpatient market share and utilization statistics, claims data often provides better overall market activity insights, including referral analyses, ambulatory/upstream market activity, and benchmarking. Healthcare organizations, particularly hospital systems, should not look to replace state data with “all-payer” claims data. Rather, utilize both to have the most comprehensive market analysis capabilities and eliminate any potential blind spots.

How Can Populi Support Your Evolving Data Strategy?

As aggregators of healthcare data, we can be your one-stop shop for external claims and consumer data used across strategy, marketing, business development and strategic finance teams. 

Have a centralized data model?

Populi leverages the most optimal setup for data liquidity, ensuring you have direct access to licensed data assets and can use them within your organization’s data environment.

Want to leverage data within your internal applications?

Populi has a set of developer APIs ready to connect, so you can use our data and analytics when, where and how you need them.

Looking for speed-to-value analytics?

Populi offers out-of-the-box analytics to help you in your data governance and front-end analytics journey by leveraging our best practices, data dictionaries and other relevant documentation and discovery dashboards.


Want to Know More?

Let’s talk about connecting analytics you care about to the platforms you work in every day.

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